Coding tells a patient's story, based on the narrative the physician provides in his or her documentation. Accurately painting a picture of the patient's severity of illness (SOI) and risk of mortality (ROM) is essential for good patient care, and it is becoming increasingly important for quality measures and reimbursement.
MS-DRGs group similar clinical conditions (diagnoses) and the procedures furnished by the hospital during the stay. The patient's principal diagnosis and up to 24 secondary diagnoses that may include comorbidities or complications will determine the MS-DRG assignment.
The MS-DRG system includes three levels of severity:
- With MCC, which reflects the highest level of severity
- With CC, which is the second highest level of severity
- Without CC/MCC, which does not significantly affect SOI and resource use
For example, a patient is admitted with acute renal failure secondary to dehydration and treated appropriately with IV fluids. The rehydration corrected the acute renal failure, and the patient did not require dialysis. Coders would sequence ICD-9-CM code 584.9 (acute kidney failure, unspecified) as the principal diagnosis with code 276.51 (dehydration) as a secondary diagnosis.
This case groups to MS-DRG 675 (other kidney and urinary tract procedures without CC/MCC). This MS-DRG has a relative weight of 1.3558, a geometric mean length of stay (GMLOS) of 1.8 days and an arithmetic mean length of stay (AMLOS) of 6.5 days.
Let's say the physician also documents that the patient is diabetic (ICD-9-CM code 250.00) and has a stage III decubitus ulcer of the heel (707.07, 707.23) that is present on admission (POA). The stage III ulcer is an MCC (as long as the ulcer is POA), so the case now groups to MS-DRG 673 (other kidney and urinary tract procedures with MCC). The relative weight increases to 3.0591, the GMLOS increases to 6.4 days, and the AMLOS becomes 9.8 days.
APR-DRGs
Most coders and CDI specialists are familiar with how MS-DRGs work. CMS implemented them back in 2007.
3M developed all patient refined DRGs (APR-DRGs) in 1990 to address both SOI and ROM over all patient populations. The APR-DRG system is composed of a clinical model and four SOI and ROM subclasses for each base APR-DRG. These subclasses are broken down into four levels:
- 1, minor
- 2, moderate
- 3, major
- 4, extreme
Hospitals use APR-DRGs for internal quality improvement, and many states use them for public reporting.
APR-DRGs are weighted according to CMS guidelines, and they are updated accordingly each year, says Sara Baine, MSN-Ed, CCDS, a CDI consultant for MedPartners HIM in St. Louis. There are expected mortality percentages based on the state data APR-DRGs, and it's a standard methodology that's used by most rating agencies, Baine adds.
Documenting SOI, ROM
In some cases a patient can look healthy on paper but in actuality has a high SOI and ROM.
Consider this case: An 86-year-old female was found unresponsive at home. Her past medical history includes:
- Diabetes mellitus Type 2
- Hypertension
- Hyperlipidemia
- Coronary artery disease
The physician documents the following information:
- Blood pressure 76/50
- Respiratory rate 8
- Heart rate 105
- Temperature 104 degrees
- Saturation on non-rebreather 87%
- Chest x-ray negative
- Complete blood cell count: White blood cell count 42,000
- Basic metabolic profile: BUN 62, creatinine 3.4
- Urinalysis: turbid urine, 4+ leukocyte esterase, greater than 50 WBCs, 4+ bacteria
The patient was given 3 liters of fluid in the ED, as well as Levophed® drip IV and Vancomycin® IV. She was intubated and placed on a ventilator.
Based on this documentation, the coder reported ICD-9-CM code 458.9 (hypotension) as the principal diagnosis, with the following secondary diagnoses:
- 599.0, urinary tract infection
- 790.7, bacteremia
- 250.00, diabetes mellitus
- 780.2, syncope and collapse
- 593.0, disorder of kidney and ureter
- 401.9, essential hypertension
- 809.7, altered mental status
The coder also reported ICD-9-CM Volume 3 procedure codes 96.71 (ventilator for less than 96 hours) and 96.04 (intubation).
The diagnoses grouped to an SOI of 1 and an ROM of 3. "The patient's healthy on paper, but really, are they?" says Rhonda Peppers, RN, BS, CCDS, a CDI consultant for MedPartners HIM. In this case, the patient wasn't. She died in the hospital on day 3.
"The mortality review appears to contradict the case as it's documented by a clinician," Peppers says. If the physicians do not document properly, they will not accurately represent the patient's SOI and ROM. "Physicians have to be sure that they document all of the treatments and add a diagnosis to it."
What should the physician have documented and what should the coder or CDI specialist have queried for to better represent how sick this patient was?
The patient came into the ED, was intubated, and received multiple medications. "You used a lot of resources on this patient," Peppers says. According to the SOI and ROM, this patient should have been walking and talking, and the facility should not have used many resources to treat her.
To accurately reflect the patient's condition, her SOI and ROM should both be 4, Peppers says. If the physician treats a condition, he or she should get credit for it. "It's a big disservice to your hospital and to your facility if you let a patient go through without showing that severity of illness and risk of mortality as what it should be to show all the resources that you used on that patient," she notes.
Most of the time with SOI and ROM, coders and CDI specialists are looking for a potential diagnosis that's not documented in the record, Baine says. The physician has alluded to a diagnosis with clinical indicators. "You've got to grab that information out and correlate it into a competent, clinical non-leading query," she adds.
Querying for SOI, ROM
Coders and CDI specialists can use a three-step approach to query for SOI and ROM, Baine says.
The first step is to review the clinical indicators. "You're determining what indicators are significant for a complex diagnosis," Baine says. Don't pull in clinical indicators that are related to something else. "You can't lump two diagnoses into one query. It would be great if we could do that because physicians get very angry if you have to place three or four queries." In addition, some facilities limit the number of queries a CDI specialist or coder can send at one time.
Step two is to look at the treatment. What kind of treatment is applicable for the diagnosis? "Don't put treatments in the query that are not essential to the diagnosis you're looking for," Baine says. Doing so could steer the physician in a different direction and be considered leading.
Step three is to determine the appropriate diagnoses for each query. The majority of queries for SOI and ROM will be potential diagnoses, Baine says. "You can't introduce new evidence, but if you can give sufficient information about what the clinical indicators are, the treatment plan that was offered, and diagnoses, if you're able to do that within your query guidelines for your facility, then you should be able to get the information you need from the physician."
In many cases, CDI specialists will need to speak to the physician face to face because the physician may not understand what the CDI specialist is looking for. The CDI specialist may need to give extra background information from the chart as well. "You can't just give the one you were looking for and say, 'This is what I need,' " Baine says. "You need to give the physician a listing of appropriate diagnoses."
Applying the query process
How would coders and CDI specialists follow this three-step process for the ED patient who died on day 3 of her stay? Coders and CDI specialists could send four separate queries for this case.
The first query involves the principal diagnosis.
Step 1, clinical indicators: 84-year-old patient with:
- Urinary tract infection
- Temperature 104 degrees
- Unresponsive
- Blood pressure 76/50
- Heart rate 105
- Saturation 87% on non-rebreather
- White blood cell 42,000
Step 2, treatment:
- 3 liters IV fluid
- Levophed drip
- Intubated/ventilator
- Vancomycin IV
Step 3, potential diagnoses:
Based on the information provided, please document if you are treating any of the following:
- Septic shock
- Shock unrelated to trauma
- Unable to determine
- Other (please specify)
The second query focuses on the respiratory problems.
Step 1, clinical indicators:
- Patient's respiration at 8 breaths per minute and oxygen saturation at 87% on non-rebreather. In addition, the patient is unresponsive.
Step 2, treatment:
- Non-rebreather progressed to intubation/ventilator management. Patient had assist control vent with rate of 12, oxygen level to 90%.
Step 3, potential diagnoses:
Based on the information provided, please document if you are treating any of the following:
- Acute respiratory failure
- Acute respiratory insufficiency
- Other diagnosis (please specify)
- Unable to determine
Some facilities may have templates for coders and CDI specialists to use when choosing diagnoses. "Make sure that you audit that and delete any diagnosis that is not pertinent or that doesn't match your indicators and treatment," Peppers says.
The third query opportunity involves the patient's unconsciousness.
Step 1, clinical indicators:
- Unresponsive to painful stimuli
- Pupils 4 mm and nonreactive
Step 2, treatments:
- Neuro checks q1h
Step 3, potential diagnoses:
Based on the above information, please document if you are treating any of the following:
- Coma
- Obtunded
- Other diagnosis (please specify)
- Unable to determine
Coma and obtunded are the only pieces of information appropriate for these clinical indicators and treatment, Baine says. "You want to give the physician sufficient information to make a valid choice so it's not a leading query."
The fourth potential query involves renal function.
Step 1, clinical indicators:
- 86-year-old patient with chronic renal insufficiency
- BUN 62, creatinine 3.4
- Documented baseline creatinine of 1
- Unresponsive
- Blood pressure 76/50
Step 2, treatments:
- 3 liters IV fluid
- Levophed drip
Step 3, potential diagnoses:
Based on the information provided, please document if you are treating any of the following:
- Acute renal failure with acute tubular necrosis
- Acute renal failure without acute tubular necrosis
- Other diagnosis
- Unable to determine
"We're looking for acute renal failure with acute tubular necrosis, and one of the reasons that we were going for the tubular necrosis is because of the blood pressure being low, 76/50, and renal failure with your 3.4 creatinine and with a baseline of 1," Peppers says.
Based on the clinical indicators and treatment, the patient's actual principal diagnosis should have been 038.9 (septicemia), Peppers says. But coders and CDI specialists need to query for that information because it is not obvious from the documentation.
In addition, coders or CDI specialists should query for potential secondary diagnoses. These should be:
- 785.52, septic shock
- 584.5, acute kidney failure with lesion of tubular necrosis
- 518.81, acute respiratory failure
- 780.01, coma
- 599.0, urinary tract infection
- 995.92, severe sepsis
- 250.00, diabetes mellitus Type 2
The procedures remain the same. This coding reflects a patient with an SOI and ROM of 4, which shows she was very sick.
Editor’s note: This article was originally published in the February issue of Briefings on Coding Compliance Strategies.Email your questions to Senior Managing Editor Michelle A. Leppert, CPC, at mleppert@hcpro.com.